Provider Demographics
NPI:1497769228
Name:SHAW, MARY LEONIE RICHARD (RN)
Entity Type:Individual
Prefix:
First Name:MARY LEONIE
Middle Name:RICHARD
Last Name:SHAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 SECOND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:35055
Mailing Address - Country:US
Mailing Address - Phone:256-739-4910
Mailing Address - Fax:256-739-9455
Practice Address - Street 1:409 SECOND AVE NW
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AZ
Practice Address - Zip Code:35055
Practice Address - Country:US
Practice Address - Phone:256-739-4910
Practice Address - Fax:256-739-9455
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10197092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry